The arguments for comprehensive parity are as strong for SA as for mental health (MH) benefits, say Yale School of Public Health professors Colleen Barry and Jody Sindelar. Although the parity bill that passed the Senate last month and a parity bill moving through the House both include SA treatment, Barry and Sindelar suggest that language in the Senate bill could allow insurers to limit SA benefits.

In recent decades, the percentage of workers with some SA coverage has increased, but so has the use of coverage limits on SA benefits, the authors note. By 2002, roughly nine out of ten workers with employer-sponsored coverage faced stricter limits on their SA coverage -- such as higher deductibles and cost sharing -- than on their general medical coverage. Only 25 percent of total spending on SA treatment is now paid for by private insurance, versus 32 percent in 1987, and the use of SA services among those with employer-based insurance declined by 23 percent between 1992 and 2001.

Both SA And MH Disorders Are Costly To Society,And Evidence-Based Treatments Are Underused

In making their case for fully including SA benefits in parity legislation, Barry and Sindelar cite several ways in which SA and MH services are similar. For example, SA disorders and mental illness often accompany each other. In addition, both SA disorders and mental illness impose significant costs on society beyond direct treatment costs: Alcohol use and psychiatric disorders ranked among the ten leading causes of disability worldwide in 1990, and SA disorders in particular impose negative externalities associated with driving while impaired and transmitting communicable diseases through unprotected sex.

Moreover, even though the evidence base for both SA and MH treatment has advanced significantly, many who suffer from these disorders receive inadequate care or even no treatment at all. “It is estimated that only 10-17 percent of those who need SA treatment receive specialty care,” Barry and Sindelar say, and among adolescents, treatment rates are even lower.

The arguments most commonly raised to support parity requirements for MH coverage apply equally to SA coverage, the authors say, For instance, advocates warn that without legislation, insurers will limit MH coverage to discourage those with chronic mental illnesses -- with their costly treatment needs -- from enrolling. This argument applies with even more force to SA coverage, since, in the private sector, “the typical treatment mode for substance abuse is more costly per unit of service than the typical treatment mode for mental health,” Barry and Sindelar state.

In the past, the inclusion of SA benefits, in addition to MH benefits, has been a hurdle for the passage of parity legislation. In 2002, when SA treatment was included in the House’s parity bill but not the Senate’s, the House dropped SA treatment to facilitate the passage of the legislation.

This year, both the House and Senate parity measures include SA benefits. However, while the House bill would require insurers to cover medically necessary treatment for all conditions included in the Diagnostic and Statistical Manual (DSM-IV) -- the generally recognized reference manual for SA and MH treatment -- the Senate bill would allow insurers to determine for themselves which diagnoses to cover.

“This difference could disproportionately affect those in need of SA treatment,” Barry explained. “More so than mental illness, addiction is often viewed as a personal moral failing rather than a disease, and there is less interest-group support for SA parity than for mental health parity. Therefore, insurers might be tempted to use the discretion provided by the Senate bill to disproportionately limit coverage for SA treatment.”

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